Geneva Lakes Family YMCA

Alert - Low

Due to the Thanksgiving holiday, the YMCA will be closed on Thursday, November 28. 24/7 access will be available. Please be sure to check our "Recent News" section to view abbreviated holiday fitness schedule for Wednesday and Friday.

Adaptive Aquatic Participant Care Form

We are thrilled you are taking a very important step to swim safety! The Geneva Lakes Family YMCA wants to know more so we can help create a program that will best meet the participant's needs. Please complete this form to the best of your ability.  Once you submit this document at the end, it will be sent directly to our Aquatics Coordinator to review and follow-up with you.  Please give us up to 48 hours to respond.  

Participant's First Name
Participant's Last Name
Participant's Date of Birth
Participant's Age
Participant's Gender
 Male
 Female
Participant's Primary Diagnosis
Participant's Secondary Diagnosis
Parent/Guardian Name
Parent/Guardian Date of Birth
Email
Address
City
State
Zip
Phone (xxx-xxx-xxxx)
Participant's Communication
 Verbal
 Nonverbal
Participant's Moblity
 Independent
 Lower Extremity Braces
 Crutches
 Cane
 Walker
Participant's Comprehension
 Gestures
 Postures
 Facial Expressions
 Spoken Words
Behavior Concerns, Sensory Aversions, Triggers, Fears things that should be avoided:
Techniques that help calm participant:
Identify the participant's strengths:
Identify goals for this program:
Please describe participant's previous swimming experience:
Please share any additional comments:
Days available:
 Monday
 Tuesday
 Wednesday
 Thursday
 Friday
 Saturday
 Sunday
Desired start time:
How did you hear about the Adaptive Aquatic program?
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